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Exercise for patients with fibromyalgia: risks versus benefits

Dolphin

Senior Member
Messages
17,567
[My primary interest is ME/CFS. I'm very interested in the "exercise issue". Anyway, I thought this might be interest so had a look. I'll copy notes in follow-up messages]

Exercise for patients with fibromyalgia: risks versus benefits.

Curr Rheumatol Rep. 2001 Apr;3(2):135-46.

Clark SR, Jones KD, Burckhardt CS, Bennett R.

Source
Oregon Health Sciences University, 3181 SW Sam Jackson, L323, Portland, OR 97201, USA.

Abstract

Although exercise in the form of stretching, strength maintenance, and aerobic conditioning is generally considered beneficial to patients with fibromyalgia (FM), there is no reliable evidence to explain why exercise should help alleviate the primary symptom of FM, namely pain. Study results are varied and do not provide a uniform consensus that exercise is beneficial or what type, intensity, or duration of exercise is best. Patients who suffer from exercise-induced pain often do not follow through with recommendations. Evidence-based prescriptions are usually inadequate because most are based on methods designed for persons without FM and, therefore, lack individualization. A mismatch between exercise intensity and level of conditioning may trigger a classic neuroendocrine stress reaction. This review considers the adverse and beneficial effects of exercise. It also provides a patient guide to exercise that takes into account the risks and benefits of exercise for persons with FM.
PMID: 11286670 [PubMed - indexed for MEDLINE]
 

Dolphin

Senior Member
Messages
17,567
These are exercise program fans so aren't going to give all the possible adverse effects.

But I think the point about overtraining in particular may be interesting.

Adverse Effects of Exercise

The potentially adverse effects of exercise depend on
the level of exercise in relation to the subjects level of
conditioning. Having FM introduces an important factor
into the equation of postexertional pain, that is, amplification
of sensory processing (ie, central sensitization)
[51,52,53,54]. Experimentally induced muscle
pain activates similar cortical nuclei to other nociceptive
inputs [55]. It is hypothesized that for a given intensity of
exercise, patients with FM will experience more postexertional
pain than patients without FM [5658]
.

Aerobic exercise is a physiologic stressor; the bodys
response is similar to psychological stressors [59]. An
elevation of stress hormones and cytokines (especially
IL-6) is a consistent feature of excessive exercise [60,61].
The magnitude of this response is blunted by regular
training. Whether patients with FM achieve the same
training effect remains unknown
.

There are some similarities between FM symptomatology
and the over-training syndrome [62]
. Overtraining
results in a syndrome of chronic fatigue, reduced
performance, depression, impaired hormonal stress
responses, and increased susceptibility to muscle damage
and infections [62]. The neuroendocrine response to
over-training is similar to reported abnormalities in FM
with a reduced hypothalamic-pituitary and autonomic
response to stressors [6365]
.

It has been observed that overtraining-induced muscle
microtrauma [66] results in an influx of monocytes
and neutrophils [67], which are responsible for removing
damaged muscle tissue as a prelude to repair. However,
muscle damage also initiates a cytokine response with the
production of large quantities of pro-inflammatory IL-1b,
IL-6, and TNF-a, producing systemic inflammation
[68]. This systemic cytokine response has widespread consequences
that include: 1) induction of "sickness" behavior,
which involves mood and psychomotor changes [69,70],
2) changes in liver function that mediate the up-regulation of
gluconeogenesis and the secretion of acute phase proteins;
this leads to a hypercatabolic state and stimulation of the
HPA axis [61], and 3) depressed immune function [71,72].
Over-training is viewed as the third stage of Selye's general
adaptation syndrome, with the focus being on recovery and
survival rather than adaptation [73]. This is considered a
protective response to minimize further excessive stress
.

There are many reports that support the notion that an
over-training reaction is more likely to occur in deconditioned
individuals [74]. Although the over-training syndrome
has been reported typically in athletes, there is
some evidence to implicate muscle microtrauma in FMrelated
muscle pain [57,75,76], which may result from
deconditioning [14,77]. Vigorous attempts to improve
conditioning may result in eccentric muscle microtrauma.

Another potential adverse effect of inappropriate
exercise is a disruption of sleep; however, this is usually
related to high-sustained exercise that is performed within 6
hours of the intended sleep time [78]. Heavy exercise or even
moderate exercise, in untrained individuals
, causes an activation
of the hypothalamic-pituitary-adrenocortical axis (HPA)
resulting in a decrease in total sleep time and slow-wave
sleep (SWS) and a delayed onset of rapid eye movement
sleep (REM)
[78,79]. An appropriate level of exertion for an
individuals level of fitness results in an enhancement of SWS
and only a moderate HPA activation reaction. Thus, it
appears that exercise may adversely impact sleep quality,
depending on whether "central" stress mechanisms are overloaded.
In other words, a mismatch between exercise intensity
and level of conditioning may trigger a classic
neuroendocrine stress reaction
[79].

While benefits of exercise are widely acknowledged, most
health professionals do not take into account the risks of
exercise once they ruled out cardiorespiratory
diseases. Patients who suffer from exercise-induced
pain often do not follow through with recommendations;
therefore, outcomes are typically disappointing. Evidencebased
prescriptions usually are inadequate because most are
based on methods designed for persons without FM and lack
individualization. While the components of fitness (flexibility,
strength, and endurance) should be included in a comprehensive
exercise prescription, one must consider the
underlying pain problems associated with central sensitization.
Muscle contraction can be a powerful pain generator
[56]. The proceeding guidelines take into account the risks
and benefits of exercise for persons with FM.
 

Dolphin

Senior Member
Messages
17,567
Other bits and pieces from elsewhere in the article

Other bits and pieces from elsewhere in the article

Few studies have attempted to analyze muscle function [3] and hardly any have addressed risks that may be associated with training.

Exercise Studies in Fibromyalgia

[..]

However, some of these studies
have been limited by attrition rates of 38% to 87% (four
of 19). Some did not report attrition (five of 19). Some
did not use a control group or meet criteria for an experimental
design (five of 19).

Busch et al. (1999)
One hundred four participants completed the study with attrition of 10.5% in the control group, 38.6% in the short-bout group, and 36.4% in the long-bout group.

Ramsay et al. [13] (2000) randomized 74 people with FM into one of two treatment groups for a once weekly, 12-week exercise study. One group engaged in 12 weekly supervised exercise classes. The other group engaged in one supervised
exercise class plus written instructions for a weekly home exercise program. The exercises consisted of aerobics, strengthening, and stretches. Neither group showed improvements in pain. The only significant finding was an improvement in anxiety in the supervised exercise group compared to the unsupervised group. At 24- and 48-week follow-up, trends toward improvement were not sustained. The authors questioned the generally held view that aerobic exercise programs are a major useful treatment for FM [13].

Jones et al.
[..]

The strengthening exercises minimized eccentric work and provided four-count pauses between each repetition to demonstrate an appreciation for the delayed return to baseline muscle tone in FM as found by Elert et al. [3].

Beneficial Effects of Exercise
That exercise is good for you is an accepted contemporary paradigm. It is well known that exercise stimulates the secretion of endorphins/enkephalins, which produce the runners high and have a beneficial impact on mood. This popular belief is based on reasonable scientific evidence, but exercise may also be bad for you, as discussed later. Whether it is good or bad for patients with FM probably depends on many variables such as age, level of conditioning, rate of increase of exercise intensity, frequency of exercise, ratio of eccentric to concentric muscle use, hormonal anabolic status, and negative factors such as obesity, arthritis, and concomitant muscle disease

Moderate exercise is a stimulus to growth hormone (GH) release in healthy individuals [47,48], and thus might be expected to have similar beneficial effects in patients with FM, some of who have adult GH deficiency [49]. However, we have reported that patients with FM have almost no response to exercise [50] and that this unresponsiveness is probably a result of increased somatostatin tone. GH is an important anabolic hormone in muscle homeostasis; thus, this potential benefit of exercise may not be attained in patients with FM.

Guide to Exercise Prescriptions for Patients with Fibromyalgia

[..]

Any exercise should be done with an appropriate amount of intensity and duration that fits the level of fitness. A general rule is to do less than the patient typically thinks can be accomplished.

[..]

Stretching
Stretching can be done daily or even several times a day.
The risk of stretching is not in stretching too often but in
stretching too far. Stretching too far may result in further
muscle microtrauma. The guide for stretching is to go to a
point of feeling slight resistance (like a tight rubber band)
and then holding for a few seconds. It is important not to
go to the point of feeling increased pain. Identifying the
stop point is easier done with the eyes closed.

Strength

Because of the painful sensations that can be experienced
with muscle contractions, many patients find that they lose
strength. This loss of strength makes the muscles more
susceptible to exertional muscle microtrauma, which typically
causes more pain (often 2 to 5 days after exercise). Thus
a cycle may be established that produces microtrauma with
increased local and generalized pain and fatigue. Strength
training programs should take into account two critical
features in patients with FM: there is a delayed onset of
muscle relaxation [3] and eccentric contractions (the major
cause of muscle microtrauma) must be minimized [80].

Rather than performing repetitions without pauses, as
is usually done, patients with FM should pause between
each repetition. For example, if performing a biceps curl,
the count would be up 1, 2, 3, 4 and down 1, 2, 3, 4 and
pause 1, 2, 3, 4. This pause presumably allows for the relaxation
phase that is delayed. To minimize eccentric work,
movements should be kept in a parallel plane rather than
done overhead
. This method has recently been tested at our
center and has been shown to be effective for improving
strength in patients with FM [2]. Our clinical experience
supports doing strength training of the upper body one day,
followed by a day of no strength training and then strength
training of the lower body followed by a day of no strength
training. This allows for the recommended twice-weekly
training of each muscle group with sufficient recovery time
[81]. Minimizing eccentric contractions is important to
reduce the occurrence of exercise-induced microtrauma
.
[45,46]. If a patient over-exerts and develops microtraumarelated
muscle soreness, the muscle should be allowed to
repair itself before exercise resumption; this will usually take
5 to 10 days. Furthermore, it is important not to overstretch
the muscles shortened from microtrauma because this will
result in further muscle damage [82]
. Figure 1 illustrates a
method that has helped many patients minimize eccentric
work when exercising and in performing daily activities.

[..]

Conclusions
Overall, moderate low-intensity exercise can be expected to
benefit patients with FM. However, it must be realized that
FM is heterogeneous in its clinical severity and secondary
systemic effects. No two patients can be treated exactly the
same when it comes to exercise prescription
. The overriding
consideration in FM exercise prescription is to avoid
muscle microtrauma and its systemic effects
. As explained
earlier, muscle microtrauma induces a stress response that
is no different from the responses to psychological or physical
stressors.

3. Elert JE, Rantapa Dahlqvist SB, Henriksson-Larsen K, Gerdle B:
Increased EMG activity during short pauses in patients with
primary fibromyalgia. Scand J Rheumatol 1989, 18:321323.

80. Bennett RM, Jacobsen S: Muscle function and origin of pain
in fibromyalgia. Bailliere's Clin Rheumatol 1994, 8(4):721746.
 
Messages
13,774
Thanks.

I spoke to someone who said that they recovered from CFS by treating it like over-training syndrome, and using the techniques body-builders etc do to recover. From a quick bit of google, it looks like over-training syndrome is pretty widely recognised, but something that's largely outside of medicine, and dealt with in the sports world. The person I spoke to said olympic trainer's etc are much more interested in understanding and fighting fatigue than GPs... it's the sort of thing which sounds plausible, but could be nonsense.

It could be that some similar mechanisms are involved for some CFS, but it looks a lot like another unexplained syndrome.
 

Dolphin

Senior Member
Messages
17,567
I spoke to someone who said that they recovered from CFS by treating it like over-training syndrome, and using the techniques body-builders etc do to recover. From a quick bit of google, it looks like over-training syndrome is pretty widely recognised, but something that's largely outside of medicine, and dealt with in the sports world. The person I spoke to said olympic trainer's etc are much more interested in understanding and fighting fatigue than GPs... it's the sort of thing which sounds plausible, but could be nonsense.

It could be that some similar mechanisms are involved for some CFS, but it looks a lot like another unexplained syndrome.
Thanks. I think comparisons with over-training might be interesting. Also, sometimes you hear of elite athletes who are said to have CFS (perhaps particularly in Australia??) - it would be presumably useful to find out if there are differences between the two as management might be different/not exactly the same.
 

Pyrrhus

Senior Member
Messages
4,172
Location
U.S., Earth

hapl808

Senior Member
Messages
2,052
Just sad that this thread started over 10 years ago. I asked so many doctors if I could do any permanent damage by pushing through my exhaustion and muscle pain and they ALL told me there was no worry of that happening. So I took the occasional Advil and pushed through and ended up alternating between housebound and bedbound instead of my busy job and life that I had before I listened to doctors.

This is why despite their schooling and expertise on many matters, there is so much hostility on forums like this one. While doctors have a lot of knowledge, they have even more arrogance about their own infallibility in areas where they have absolutely no clue what they're doing, and absolutely no regret on the lives they destroyed.
 

Pyrrhus

Senior Member
Messages
4,172
Location
U.S., Earth
Just sad that this thread started over 10 years ago.

Even sadder: 20 years ago, the Canadian National ME/FM Action Network, a long-standing Canadian advocacy organization, spearheaded the development of a "Canadian Consensus Criteria" for diagnosing fibromyalgia, which they abbreviate as "FMS".

Here is a passage from their overview document, describing the complete lack of any evidence for the use of exercise in fibromyalgia:
Although exercise is the most prescribed nonpharmaceutical treatment, there is no reliable evidence that would explain why exercise should reduce [fibromyalgia FMS] pain. In a systematic review of 1,808 multidisciplinary studies, only 2 studies including exercise for FMS met the criteria for methodology, and the results were disappointing.

Jones et al. reviewed 26 studies of FMS exercise programs, which also did not provide a consensus that exercise was beneficial for FMS patients. The generally disappointing results combined with attrition rates running as high as 60% and 61% (some studies failed to disclose their attrition rates) suggest these programs failed to meet the patients’ needs.
Source: https://www.sacfs.asn.au/download/consensus_overview_fms.pdf
 

Marylib

Senior Member
Messages
1,155
All I know is that when I was typical FM I could exercise all I wanted to. It helped with the fibromyalgia pain. Exercise and athletics felt great - no PEM. (I couldn't sleep properly and I had muscle pain.)

Then came one more flu - I got over that - and then it all changed. I remember the exact moment. An entirely different disease. It may not be true for everyone, but I perceived them that way.
 

Pyrrhus

Senior Member
Messages
4,172
Location
U.S., Earth
All I know is that when I was typical FM I could exercise all I wanted to. It helped with the fibromyalgia pain. Exercise and athletics felt great - no PEM. (I couldn't sleep properly and I had muscle pain.)

That's very interesting, thanks for sharing. Was your "typical FM" consistent with the current (2018) diagnostic criteria for fibromyalgia?

(It seems that a LOT of people with widespread chronic pain had been misdiagnosed with fibromyalgia in the past!)
 

Marylib

Senior Member
Messages
1,155
Pretty much. When I was first diagnosed with ME, she said that in one sense it was a gradual onset. But when ME hit it was like falling off the cliff and FM was the good old days.